PROJECT SUMMARY One in four US women report at least one pelvic floor disorder such as prolapse, urinary, or fecal incontinence, while nearly one in five US women undergoes surgery for stress urinary incontinence or pelvic organ prolapse by age 80. The only meaningful alternative to pelvic floor surgery is the pessary, an intravaginal device that relieves symptoms and provides support to the pelvic organs. Unfortunately, approximately 50% of women who undergo pessary treatment do not continue with this non-surgical option. These women go untreated, or proceed to pelvic floor surgery with an increased risk of peri- operative complications and death directly related to increasing age. To avoid surgical risks in aged women, and address a prevalent problem that disproportionately affects older women, there is a critical need to understand why women do not continue with non-surgical treatment. This study will focus on the host response to a pessary. Ultimately, we aim to identify barriers to effective non-surgical management of pelvic floor disorders in the elderly. We hypothesize that the vaginal environment in elderly women with a pessary is distinct from the vaginal environment of elderly women with no history of pessary use. Hence our specific aims are 1) to determine the predominant vaginal microorganisms of older women with and without a pessary by using standard culture techniques, expanded quantitative culture techniques and matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). 2) To determine the vaginal AMP profile of older women with and without a pessary by assessing AMP activity using high pressure liquid chromatography fractionation and radial diffusion assay to assess for candidate AMPs (cathelicidin, beta defensisn (hBD1 and vBD2) psoriasin, lactoferrin). 3) To determine longitudinal changes in the vaginal microbiome and AMP profile between women who choose to continue pessary use and those who do not by comparing the data from Aim 1 and Aim 2 with the clinical characteristics of continued pessary use and functional age status. This innovative project represents a significant transition into aging research for the PI, Dr. Cynthia Brincat, and would begin to establish her career into aging science, as well as that of her interdisciplinary team. Our studies will advance the care of elderly patients by providing a better understanding of the vaginal microbiome and AMP activity in elderly women. Consequently, we will be able to characterize the host response to pessary therapy. In characterizing the vaginal environment of pessary users, we can ultimately aim for novel targets for pharmacologic treatment of the vaginal microbial community, potentially allowing patients to continue with non-surgical therapies rather than pursuing surgical intervention.